Enrollment Application Form | GCE Registration

Important Information

*Fields marked with (*) must be completed.

* Uploaded documents must be clear, valid, and readable.

Email Verify

Email Address *

Candidate Registration

Center *

Type of Course *

Select Course *

Select Class *

Registration Amount

Application Fee

$0.00

Candidate Details

First and Last Name *

Additional Name(s) (Optional)

Maiden Name

Date of Birth (MM-DD-YYYY) *

Gender *

Race *

Submission Date (MM-DD-YYYY) *

Residential Information

APT / Unit Number (Optional)

Address Line *

Town / City *

Region / State *

Postal Code *

Communication Details

Primary Contact Number *

Mobile Number *

Alternate Contact Number (Optional)

Identity & Eligibility

Social Security Number *

Nationality Status *

Do you have authorization to Test in Missouri? Can you participate in Clinicals in Missouri? *

Yes

Emergency Contact

Contact Person Name *

Relationship to Candidate *

Emergency Contact Number *

Background Information

Ethnic Background (Optional)

Collected for reporting purposes only

How did you hear about Green Creek Education? *

Online Search

Educational Institution

Social Media (Tiktok- Facebook- Instagram)

Recommendation

Other

Prior Academic Restrictions

Have you ever been convicted of a criminal offense that may affect eligibility for healthcare training, clinical placement, or state certification? *

Yes

Supporting Documents

Valid Government ID *

Passport or National ID

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Recent Photograph *

Passport-size image

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

SSN Card *

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Previous Academic Records (Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Proof of Residence (Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Skin Test for Tuberculosis(Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Immunization Records(Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

High School Diplomas(Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Covid-19 Vaccine Card(Optional)

Drop file here or browse

PDF, JPG, PNG (Max 10MB)

Fee Payment Options

Payment Method *

Scholarship Partners *

Pay In *

100% at once

I am fully committed and ready to begin.

50% now + 50% later

I am ready to start as soon as my background check is complete.

75% now + 25% later

I am eager to receive my book and start once my background check is complete.

Pay in 4 installments

I need more time to make payments, but I am fully committed. I understand that the course will not unlock until I have paid 50%.

Contract Acceptance

I, the undersigned, have read and understand this agreement. It is further understood and agreed that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement on the student and the School Official. I also understand that if I default upon this agreement, I will be responsible for payment of any collection fees or attorney fees incurred by Green Creek Education.

My electronic signature below signifies that I have read and understand all aspects of this agreement and recognize my legal responsibilities regarding this contract.

Candidate Agreement & Signature

I hereby certify that I have reviewed and understood all registration requirements and agree to be bound by the regulations governing GCE examinations.

Name *

Date Signed (MM-DD-YYYY) *

Digital Signature *

Sign electronically in the box below

Additional Attachments (Optional)

Drop files here or browse

PDF, JPG, PNG | Max 2MB per file

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